This report is made in a bona fide belief that litigation may ensue and to enable the Employer's Representatives, Solicitors and/or Agents to conduct and advise in relation to such litigation.

Policy Holder (required)

Name of insured

Policy Number

Your Email

Address

Postcode

Business

Tel. No

Are you registered under VAT regulations?

If Yes please give details

Employees Details (required)

Name of Employee

Date of Birth

Age

Occupation

Staff Number

Address

Postcode

Is he/she in your direct employment?

National Insurance No.

How long has he/she been in your employment?

Average net weekly wage

Details of Accident (required)

Date

Time

Place

Describe what the employee was doing and how the accident happened.

Nature and extent of injury/ disability

Has the accident been reported to the Health and Safety Executive?

Have they carried out an investigation?

Has the Employee resumed work?

If so, When?

If not, what is the expected duration of the incapacity?

To whom and when did the Employee report the accident?

Witnesses

Give Names and Addresses

Data Protection Notification
We may use personal and business details you give us, or which are supplied by third parties, to consider your claim, to search the files of credit reference agencies who may keep a record of the search, to carry out such financial and other enquiries as we consider necessary to evaluate the claim and assist in making a decision regarding the claim, and the compliance business reviews.
We may also share these with other insurance organisations and selected other parties to handle claims and prevent fraud.
Personal details may be transferred to countries outside the EU. They will at all times be held securely and handled with the utmost care in accordance with all principles of UK Law. We will store such personal derails on computer but will not keep them for longer than necessary. Under terms of the Data Protection Act 1998, individuals are entitled to a copy of all the information we hold about them.

VERY IMPORTANT - FRAUDULENT AND EXAGGERATED CLAIMS Deliberately exaggerated claims could invalidate your policy cover. Insurance fraud is a crime and liable to prosecution.
The above answers to our questions will be the basis of consideration of your claim. You must ensure that all information is true and correct to the best of your knowledge and belief, and that all material facts have been disclosed.
A material fact is one that is likely to influence us in the assessment or acceptance of this claim, or one that is likely to influence our consideration of cover under the terms of your policy.
If you are in any doubt as to whether a fact is material, you must disclose it.

FAILURE TO DO THIS MAY MEAN THAT YOUR POLICY BECOMES INVALID AND A CLAIM PAYMENT WLL NOT BE MADE.
I/We declare the foregoing particulars to be correct according to our information and belief. I/we understand that you may seek information from other insurers to check the answers I/We have provided. This report is made in the bona fide belief that litigation may ensue and to enable solicitors and/or agents to conduct such litigation and advice in relation thereto.